Provider Demographics
NPI:1134281132
Name:GRAND TRAVERSE BAND OF OTTAWA AND CHIPPEWA INDIANS
Entity Type:Organization
Organization Name:GRAND TRAVERSE BAND OF OTTAWA AND CHIPPEWA INDIANS
Other - Org Name:GRAND TRAVERSE BAND FAMILY HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LOI
Authorized Official - Middle Name:E
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-534-7477
Mailing Address - Street 1:2300 N STALLMAN RD
Mailing Address - Street 2:
Mailing Address - City:SUTTONS BAY
Mailing Address - State:MI
Mailing Address - Zip Code:49682-9158
Mailing Address - Country:US
Mailing Address - Phone:231-534-7200
Mailing Address - Fax:231-534-7460
Practice Address - Street 1:2300 N STALLMAN RD
Practice Address - Street 2:
Practice Address - City:SUTTONS BAY
Practice Address - State:MI
Practice Address - Zip Code:49682-9158
Practice Address - Country:US
Practice Address - Phone:231-534-7200
Practice Address - Fax:231-534-7460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1376553586Medicaid
MI700D545020OtherBCBS
MI1376553586Medicaid
MIOM65120Medicare ID - Type Unspecified